Clinical care rendered by physicians and other health care providers is reviewed for utilization management, quality of care, and other review or analytic functions by reviewing entities charged with these functions. Utilization management is usually performed by a health maintenance organization (HMO) or other managed care organization (MCO).
When a healthcare provider (HCP) examines and treats a patient, the HCP records the examination in a clinical chart. Under industry custom, designated personnel at the health care provider's site extract clinical information from the chart and transmit the clinical information to the reviewing entity by telephone or fax.
At the reviewing entity, personnel manually input this clinical data into an electronic form which contains one or more text fields. The information is then reviewed by one or more professional personnel to determine appropriateness of care. Determinations of the appropriateness of care are then communicated back to the health care site by phone or fax (negative determinations also require a formal letter of denial).
Because the clinical information is typically input into text fields without any formatting, the reviewing organization cannot electronically evaluate this data for appropriateness of care; instead, determinations must be made manually. As a result, determinations can be inconsistent for similar clinical situations when evaluated by the same reviewer or among multiple reviewers. There is almost no way to systematically evaluate this data among multiple clinical episodes to identify and evaluate patterns of care.
Quality of care for hospitalized patients has been nationally recognized as a major issue in health care. Review of inpatient care is sporadic and often only after an adverse event. Routine and comprehensive review of each inpatient admission and daily hospital care would improve quality of care. Physicians' care for their inpatients is not routinely reviewed proactively for quality of care. Medical therapies, endoscopies, other diagnostic testing and surgeries are not proactively re-viewed for clinical appropriateness.
Patients, particularly in-state Medicaid plans, may use the Emergency Room (ER) as their source of non-emergent primary care. Since the cost of care in an ER visit far exceeds the cost of providing care in a doctor's office, inappropriate use of the ER is a great burden to managed care organization, states, and hospitals when there is no reimbursement for the visits. Claims for ER visits may be paid on the basis of diagnosis, without review of the ER record. States generally have a law that compels payment for Emergency Room visits for illness and injuries that are thought by the average person to be dangerous, which is termed the “Prudent Lay-person Law”.
Providers of healthcare services including hospitals, clinicians, durable medical equipment com-panies and companies providing parenteral medications may provide their services to patients who are members of a managed care organization (MCO). These healthcare providers may seek reimbursement for one or more services provided to a patient from an MCOs who may reject claims for payment of services. These denials of payment may be for multiple reasons, but usually are on the basis that the service or services did not meet clinical guidelines.
The healthcare provider usually has an opportunity to appeal a denial of payment with a rebuttal based on clinical rationale, which is supported by clinical information extracted from from the patient's clinical record for the denied service or services. The review and extraction of supporting clinical data is often relegated to third parties, which may be cumbersome and inexact.
The Appeals system enables providers of health care services to respond to denial of payment for services performed, including clinical care services and provision of medical equipment, usually by managed care organizations using clinical data derived from electronic clinical charts to sup-port the clinical rationale.
Electronic clinical charts in healthcare has been a largely unfulfilled goal in this era of increasing computerization, most clinicians still using paper clinical charting to document health care. Without the buyin of clinicians, the goal of electronic clinical charting will continue to be elusive.
Reasons for resistance to using electronic charting include cumbersome labor intensive computer interfaces, requiring multiple screens, manual data entry in multiple formats, existence of multiple differing proprietary applications which may use older technology and unavailability of a uniform charting application at multiple care locations, such as hospital, office or clinic.
In this internet era of increasing patient self-education, a patient can review his or her healthcare by researching individual diagnoses and symptoms on-line. Usually, the information is not customized to a patient's specific constellation of signs, symptoms and specific medical status. Usually a patient cannot evaluate the doctor's care specifically referenced to his or her own medical status, including appropriateness of diagnostic work-up and therapies.